Lab Data Requirements and Health Data Capture

The Centers for Medicare & Medicaid Services regulates laboratory testing performed on humans in the U.S. through the Clinical Laboratory Improvement Amendments (CLIA) to ensure quality laboratory testing. CLIA sets high standards for quality control, validation of data and tests, equipment calibration, proper training and certification of users and clear end result reporting that meets proper lab data requirements.

Complying with CLIA requirements creates a necessary and significant impact on your human resources. When you receive orders on paper or electronically from performing labs outside of your area, you may already have the feeling of being continually challenged with every accredited organization's survey of your records. Your patients routinely generate paper or faxed (electronic) results from your outreach or ambulatory clinics that require human data transcription. You receive a variety of results values from a broad list of performing labs. You may feel that you have experienced and competent staff, but let’s be honest; nobody is a perfect typist. 

Your physicians need a comprehensive patient record for all patients every time they open the patient record; they need accurate and complete information to provide the quality care your organization promises. It’s there on your home page, it’s the first message your future patients or subscribers see; excellence in healthcare.  

Let’s say the only way you are able to get some or all of the tests into your patient’s health record is to have a person enter this information. Do you have controls in place to monitor for quality? Do you worry about your next survey or complaint?

There is a unique software solution that can automatically find critical data elements trapped in paper or faxed test results and incorporate it into the EMR. Built-in controls in its rapid verification panel help ensure test reports include the following CLIA required data elements:

  • Name and address of performing lab
  • Ordering physician
  • Test report data
  • Test results and units of measurement or interpretation
  • Reference intervals
  • Collection data
  • Positive patient identifier

Productivity and accuracy-enhancing features further leverage automation to handle this challenging workflow:

  • Users are automatically notified when duplicate documentation is received.
  • EMR order numbers and patient MRNs are retrieved once an order has been resulted to match orders/procedures.
  • An audit trail provides a valuable quality control tool for reviewing user activity and analyzing workflow.

Get you more information.

Schedule a conversation with a health information specialist to better understand how you can automate workflows for handling non-interfaced lab results.

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About the Author: Greg Gies

For 20 years in the software industry, Greg Gies has been helping businesses, government agencies and healthcare organizations achieve their goals and carry out their missions by making better use of information and automating business processes. Greg has held positions in sales, product management and marketing and holds an MBA from Babson College. He works and lives with his wife and three boys in the Boston area.